Do Integrated Care Models Strengthen Transitions of Care in Post-Acute Care?

Health care in the US often functions in silos, creating obstacles to navigate during transitions of care, especially transitions involving medically complex older adults receiving care in post-acute care settings such as skilled nursing facilities (SNF) and long-term care (LTC). Recently, value-based payment models and the COVID-19 pandemic have accelerated the need to implement more collaboration and integrated care delivery systems.^1,2

The lack of consensus on the benefits of integrated care has dampened its widespread dissemination and contributed to controversy over its adoption. Some literature suggests that benefits of integrated care models include improved hospital admission rates, readmission rates, length of stay, Medicare payments and patient satisfaction.^3-8 On the other hand, repeated studies have not verified such outcomes. For instance, a medication safety alert system linking SNFs to community primary care providers was unable to reduce hospital readmission or adverse drug event rates.⁹ Readmission rates and mortality were not improved in a study of integrated hospitals and SNFs,⁵ and integration of physician practices with hospitals have exhibited higher commercial prices and increases in spending for outpatient care.¹⁰

SNFs seeking integrated care models to improve transitions of care face many barriers. Nursing facility staff often identify inefficient information transfer an impediment to carrying out essential transitional processes such as medication reconciliation.¹¹ Barriers to collaboration with acute settings include misaligned incentives, fragmented discharge planning, and disconnected understandings of the complexity between the unique environments.⁸ Regulatory challenges, such as limits to the use of telehealth in SNF and a hybrid environment with some medical providers operating under fee-for-service and some primarily under value-based payment, make integrated care challenging to embrace.

The COVID-19 pandemic, with the ensuant expanded regulations for telehealth and coverage for SNF stays, is paving the way toward more integrated care and propelling the value of integration to the forefront. Although the impact of integrated care delivery during the pandemic still requires study and understanding, incorporating integrated care processes into SNF care could strengthen transitions of care for post-acute patients beyond the pandemic. Based on themes from a brief literature search and our personal experiences, this article highlights integrated care processes that demonstrate positive impacts on SNF patients’ transitions of care in the following broad categories: health information exchange, shared consultation and education, and mobilization of health care resources (Table 1).

Table 1. Integrated Care Models Benefiting Transitions of Care

Abbreviations: ECHO, Extension for Community Healthcare Outcomes; LTC, long-term care; SNF, skilled nursing facility.

Drawing from the evidence cited, we present suggestions for overcoming existing barriers to promote integrated care processes that positively impact transitions in post-acute care (Table 2).

Table 2. Barriers to Implementing Integration Process in Transitions of Care With Recommendations for Practice and Policy Reform
 

Abbreviations: ACO, Accountable Care Organization; aLOS, acute length of stay; BPCI, Bundled Payments for Care Improvement; CMS, US Centers for Medicare & Medicaid Services; EMR, electronic medical record; ECHO, Extension for Community Healthcare Outcomes; HIE, health information exchange; LTC, long-term care; SNF, skilled nursing facility.

Effective transitions of care to post-acute settings have long depended on high levels of collaboration between care settings. The ability to seamlessly share health care data is a potential strength of integrated care models, but commonly, a lack of interoperable electronic health records and lack of transparency between organizations for timely, accurate exchange of information necessitate more direct contact between providers. Sharing information via planned conferences and joint documentation between acute and post-acute clinical teams has fortunately been associated with improved coordination of post-discharge services, direct and accurate sharing of medication lists, and more accurate advance care planning.^12-14 In efforts to integrate with more efficient transfer summaries, implementation of customized transfer forms populated with relevant clinical information during, not after, hospitalization has been associated with decreased readmission rates after transfer to SNF.¹⁵ Additionally, SNFs receive more complete, timely and usable information when a hospital-based clinician maintains a presence in post-acute care, as suggested by 500 SNFs surveyed regarding integration with local hospitals.¹⁶

Clear consultation structures across settings expand the clinical expertise available, helping post-acute care settings appropriately manage transfers.¹⁵ Synchronous and asynchronous forms of consultation utilizing telehealth bring together providers that may be otherwise difficult to access for collaboration on SNF patient management and promote a culture of in-house care when appropriate.^17,18 Clinical pharmacists dedicated to medication reconciliation for SNF patients transitioning across the continuum are uniquely qualified to resolve medication dosing errors and errors of omission or commission that create hazards during transitions of care.^14,19 Even systematically allowing written communication between LTC clinicians and specialists can result in new courses of action and problem solving during transitions without additional transfers of patients to clinics and hospitals.¹⁷

Integrated care models allow for distribution of staff and physical supplies beyond the resource capacity of a patient’s current clinical setting. In some models, health care workers such as community paramedics and nursing aides receiving standardized training to apply skills across the health care continuum have shown the capacity to provide acute care services to LTC communities and reduce transfers to acute care.^18,20 Multidisciplinary teams, medical equipment, and medications are resources that enable hospital-level care for those in the community, including SNF and LTC.¹⁵ In a Swedish regional health care organization targeting older adults discharged from acute care, integration allows resources to be pooled and redistributed to LTC settings, resulting in improved costs and quality.¹² Mobilizing additional resources to serve LTC patients enables the delivery of higher-acuity care within the LTC setting.

New processes for data transfer and communication of health information have accelerated in recent years to support transitions of care whether or not post-acute settings are prepared for integration. During the COVID-19 pandemic, innovative protocols for exchanging health information have quickly emerged, at times utilizing existing lines of communication, such as fax machines, rather than requiring complete system overhauls.²¹

With telehealth, it is possible to incorporate more vast clinical expertise to facilitate appropriate transitions of care and avoid unnecessary transfers. Telemedicine facilitates concurrent management of acute changes in condition by both bedside and remote clinicians, a collaboration patients may otherwise benefit from only in acute care settings.¹⁷ Nursing leaders, medical specialists, psychologists, and infection preventionists from acute care settings may remotely provide active infection advisory consultation to limit COVID-19 outbreaks in SNF and LTC communities as well as guide decisions on medically necessary transfers to emergency departments and hospitals.^17,22

Routine clinical discussions and interactive webinars such as those of Project ECHO (Extension for Community Healthcare Outcomes) allow collaboration with academic medical centers on clinical management that would otherwise be difficult to access in LTC.²³ Throughout the COVID-19 pandemic, sharing best practices with experts has helped SNF and LTC staff feel more comfortable with treat-in-place protocols. Improved staff comfort may contribute to the positive outcomes demonstrated by these models of collaborative, shared expertise between acute and post-acute settings, namely decreased hospital referrals and increased survival of patients with COVID-19.²⁴

Transitions of care continue to benefit from integration of staff and physical resources. Consolidation of resources, such as personal protective equipment, medications, and patient-care areas, has been integral in the COVID-19 pandemic response, reducing transfers prompted by scarce resources.²³ The combined the efforts of LTCs, SNFs, hospitals, and other community partners helps to ensure equitable access for patients across the continuum of care.

It may be controversial whether the available evidence on integrated care models is sufficiently robust to inform widespread, systemic practice.¹⁵ However, many existing integrated care models currently suggest outcomes with more effective patient-centered transitions for SNF and LTC patients. Unprecedented disruption imposed by COVID-19 has led to rapid implementation of integration among health care settings that has yet to be evaluated. As such, until further research demonstrates harm or detriments, LTC communities may choose to implement processes of integrated care, such as enhancing transparent communication of health care information, establishing rapid medical consultation, or consolidating sparse physical resources in ways that facilitate high-quality care and continuity across settings. As we have set forth in our recommendations for practice and policy reform (Table 2), we hope that LTC providers will work together to overcome current barriers of integration that may lead to safer, more seamless transitions of care for patients in post-acute care settings.

Sing Palat, MD, CMD^1,2 • Mamata Yanamadala, MBBS, MS³ • Vishal Kuchaculla, MD⁴ • Christian Bergman, MD, CMD⁵ • Manisha Parulekar, MD, AGSF, CMD⁶

Affiliations:
¹Division of Geriatric Medicine, University of Colorado, Denver, CO
²LTC Rehab Consultants, Arvada, CO
³Division of Geriatrics, Duke University Medical Center, Durham, NC
⁴Vantage Healthcare, Canton, MA
⁵Division of Geriatric Medicine, Virginia Commonwealth University, Richmond, VA
⁶Division of Geriatrics, Hackensack Meridian School of Medicine, Hackensack University Medical Center, NJ

Disclosures:
The authors report no relevant financial relationships.

Address correspondence to:
Sing Palat, MD
169 Inverness Drive West, Ste 400
Engelwood, CO 80112
Email: spalat@ltcrehab.com